a sufficient length of stay

An Article By Scott Eberle, M.D.

In hospice circles, a person who dies within a week of admission is said to have had “a short length of stay” – “SLOS” for short. This is not uncommon, as balancing the desire for life-prolonging therapies and a quality end of life is often challenging. Nationwide, about 35% of all hospice admissions are short lengths of stay, while at our hospices, the number is about 25%.

“I’m calling about Aunt Fiona,” said my mother, her voice cracking. “She’s decided to quit all treatment and leave the hospital. Daniel says she’ll be coming home tomorrow with hospice there to meet her.” “I’m so sorry to hear that Mom.” “Tell me about it! I’m having such a hard time believing this. Last time we saw her she was so alive, so vibrant. And that was just four months ago. I don’t understand why she would give up like this.” “You’re right. Hard to reconcile the news with who we saw at the beach house in August.” I, too, was surprised – not by my aunt’s decision to choose hospice, but by how soon she had reached this final stage of life. Intuition (and years of hospice experience) told me that Fiona’s “giving up” was likely a wise choice. She was a sharp, no nonsense, in control person: the sort who wouldn’t hesitate to fight the good fight – but only for as long as it made sense. She would not be the person still reaching for the brass ring of a miracle cure, as the medical merry-go-round spins out of control and then tosses her off. She would not be a person sent home to die a day or two before the end – barely conscious, barely able to communicate. She needed her last days to be in her own home and with her own family. Fiona was determined that her version of “SLOS” would be a sufficient length of stay, not a short one.I decided to draw my mother out, to have the two of us trace out Fiona’s story-line: from vacation at Stinson Beach, to the first news of her ovarian cancer, through chemotherapy, onto surgery, and now with hospice. I wanted to give her (and me) a chance to let the latest news sink in. In the fall we received initial word about Fiona’s diagnosis of ovarian cancer, and we were all stunned. Two months earlier she and Uncle Daniel had joined my family for a week’s holiday at Stinson Beach and she had seemed fine: looking younger than her 65 years, and as feisty and engaging as ever. Either she had had no health problems then, or she was hiding them behind a stoicism learned during her post-World War II youth in Northern England. But ovarian cancer is often referred to as “the silent killer” – some women have so few symptoms – and so I assumed that even she had not known at the time. Soon after the diagnosis she started sending out long engaging e-mail rambles with titles like “On being a cancer patient” and “Living (or dying?) with cancer.” She told us how she had loosened her tight budget on red wine, now allowing herself to splurge at $12 per bottle instead of buying cheaper wine by the case. You could see her wry smile as she then added: “But let me tell you, if the prognosis worsens, I’m going up to $25 a bottle.” The guilt-free pleasures didn’t stop there. Long walks with her cocker spaniel (her energy was still good). The return of an old addiction to clotted cream. A new-found ability to luxuriate in bubble baths instead of taking short Spartan showers. In short, she was enjoying life. In early December, though, her entertaining missives stopped, replaced by foreboding updates from Daniel, her devoted husband. She’s off to the hospital for surgery. She’s refusing any phone calls, including from her children. She’s unable to move her bowels, and therefore unable to go home. “I hate to say it, Mom, but replaying the whole story, this latest news is not really a surprise after all. My guess is she’s got only weeks left, not months. With that amount of time before you, new priorities come into view.” I paused for a while to let that land, and then added: “And I don’t mean buying expensive bottles of red wine.” We allowed ourselves a short laugh, enough to lighten the moment. “You’re right,” she conceded. The truth of the situation had finally sunk in. “Of course, you’re right. I’m just so sorry to be losing her.” And lose her we did – three weeks later, just after the start of the New Year.But not until Fiona had had the time she needed at home. Time to meet the hospice nurse – soon to be a trusted ally – who greeted her arrival home with a hospital bed and a gentle touch. Time to get comfortable, deeply comfortable: in her own house, in her own bedroom, in her own body. Time to surrender to the precious moments that still were hers to enjoy, including the occasional sip of an expensive Merlot. Time to say a full and tender goodbye to those she most loved: Daniel, her two children Ruth and Richard, and her dog Molly. Not enough time, to be sure. Not nearly enough time. But a “sufficient length of stay” nonetheless.

Dr. Scott Eberle has been medical director at Hospice of Petaluma for 22 years. This story is based on the recentpassing of a dear family member of his, though details have been altered to maintain her anonymity.